Provider Demographics
NPI:1225063233
Name:WHITCOMB, LARRY DALE (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DALE
Last Name:WHITCOMB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540040
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0040
Mailing Address - Country:US
Mailing Address - Phone:972-988-1006
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-8312
Practice Address - Country:US
Practice Address - Phone:806-778-4457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5798208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089609401Medicaid
TX089609401Medicaid
C23382Medicare UPIN